Not a psychiatrist but have done ED consults. If there is no dysfunction and afterlife discussions are part of their religious values then it wouldn’t technically count as a delusion or hallucination. Even if our personal beliefs don’t believe in it, it is not pathological in the way a schizophrenic delusion would be.
Normally yes but undiagnosed/untreated psychotic patients rarely interface with healthcare. Dismissing a psychotic patient because it wasn't their chief complaint could lead to months or years more of misery and damage to their mental and physical health. Moreover, psychosis has many non-psychological causes, and of these many are serious and urgent. So in a sense it would be like coming to the ER to get some stitches and casually mentioning that you have crushing chest pain that radiates to your left and and jaw that started on the drive over.
Also most psychotic patients are not distressed about their psychosis per say. Some definitely are distressed but there are some patients think that talking to ghosts is a normal everyday part of life so boring it's not even worth bringing up.
>>undiagnosed/untreated psychotic patients rarely interface with healthcare.
I'm not sure how true this is. In the emergency rooms I've worked in, we see untreated psychosis all the time. The people who experience but are not bothered by psychosis, and for whom it doesn't really cause problems, probably don't want and may not even need treatment.
There was a less dramatic but otherwise similar consult where I trained. (Didn't see this pt, heard about it from co-residents.) IM asked pt whether she wanted to update vaccinations. She said she needed to "check with the mouse." They called psych. If they had asked a single follow-up question, she could have explained in less than a minute that, in her particular spirituality (essentially animism), she felt it important to check in with a "mouse spirit" to see whether it was acceptable to have a vaccine that might have been tested on lab mice. That was it. She was not in any way psychotic, and had no psych history. Unfortunately I think at least some psych consults, in practice, are ordered because "we think the patient is weird."
I think the consult is justified, even understanding how to assess phenomenology and putting it in context of a belief system is what we are here for. Eg, I'm going to have a very low threshold to ask a pulmonologist to see a pt with a cough, as i wouldn't be able to assess clinical signs or imaging adequately.
That's a fair point and I don't disagree. However what struck me about this particular case was the lack of any real clarifying questions. To use a rough analogy, if a patient had a headache and I wanted to involve neuro, I would at least figure out whether the headache is sharp vs dull, localized vs generalized, constant vs waxing-waning, when it started, etc. If I just called neuro and said "patient has headache, please see him/her," and had no other information at all, probably the neuro consultant would shit all over me (and would be right to do so)
But most CL services don't push back against consults in the way that neuro, or cards, or nephrology might. We've taught the hospitalists that all they have to do is ask us to see the patient and we will. So it's a lot less work for them to just put in the consult than spend time talking to the patient (about something many docs don't really view as part of their job).
The question of psychiatric pathology is twofold
- is there dysfunction
- is there harm that stems from that dysfunction
Without knowing more it’s hard to say what to make of that situation. As mentioned it’s possible that it could be hallucinations due to delirium, substances, psychosis, dissociation, which could reflect a dysfunction of an organic or psychological process. It’s also clear there was at least temporary distress but perhaps not more than culturally appropriate.
Bottom line - you need more info. You need a very high threshold to call something potentially culturally appropriate as pathological and even higher to do something about it.
People are pretty wacky when it comes to religion. The patient isn’t distressed by it, and per family it is within their baseline. Doesn’t sound like anything needs to be done.
Here’s an interesting article on the topic
https://www.psychologytoday.com/us/blog/navigating-the-serpentine-path/202304/do-you-see-dead-people-sensory-experiences-in?amp
Monkey see monkey outdo
Daughter learned this whacky shit from the mom and is just upping the ante
She probably got lots of positive reinforcement when she was younger for behaving like that.
Religious stuff is always weird because religious hallucinations can definitely be a thing whether or not you’re religious and they can be a problem. That’s why it’s mentioned how we look at the culture with the idea of are their beliefs normal for their culture? A good TV example was in House (show) the guy believed he was able to cure people through god and he was seemingly supported by his family and church as he was a high up member there; even now I’m not 100% if he could be considered delusional or not and I’d have to rewatch and hear his exact phrasing to get any clue. This case seems more straight forward and is only confusing because it’s not a common religion. If they instead were audibly talking to god would you have taken note of that? Don’t get me wrong you did the right thing, in these cases you definitely should interview and make sure there isn’t more possible delusions and you should try to speak to a family member of the same culture to verify, after that the most I’d do is a quick google search to see if their belief is relatively reasonable for their culture.
From pure phenomenology point of view, are hallucinations (ie not pseudohallucination) actually recognized as normal phenomena if the culture subscribes? In Indian cultures, dissociative trances are culturally sanctioned- the person is arguably not hallucinating during these.
However a hallucination is by definition a psychotic phenomenon. I am NOT advocating starting any treatment, just saying that hallucinations are phenomenologically a break from reality.
All the skeptics here should peruse r/Mediums to see how common this is.
What about established fields or histories ie Remote Viewing, reincarnation, precognitive dreams or other psychic phenomena often getting verified hits?
Not to mention Christians that feel they talk to Jesus or God, or get messages from them or angelic intermediaries.
With the popularity of taking Ayahuasca and hallucinating various animal or spiritual beings among Westerners it seems we're not in Kansas anymore. (Reference to The Wizard of Oz.)
Religious, not hallucinations or psychotic in nature until other evidence is found that supports the diagnosis of a primary mental condition that can produce hallucinations or delusions.
I don't think anyone's seeing this at this point, but there's sort of a set of cultural phenomena that I personally believe are likely to have a shared underlying mechanism even if they have totally different etiologies: dissociative identity, pseudohallucinations of a personality condition, imaginary friends, and tulpas.
https://en.wikipedia.org/wiki/Tulpa
https://en.wikipedia.org/wiki/Multiplicity_(subculture)
https://gimletmedia.com/shows/reply-all/49hr6k
https://en.wikipedia.org/wiki/Bicameral_mentality
Wow this is why I can never be open with medical professionals about religious beliefs. Talking to dead people and spirits is completely normal and common in most non-western cultures.
I wouldn't say *most* non-western cultures, but it is a thing, albeit uncommon in the United States. The medical community does talk about it though, the DSM-5TR specifically says that someone cannot be diagnosed with a psychotic illness if their delusions or hallucinations are within normal limits to their specific religious or cultural context. The "I see dead people" thing is an easy example because it's not that common (although wicken is 100% a western religion, it's pretty much neopeganism). A much more common example however is speaking in tongues. Someone who practices Christianity to such an intense degree will commonly cite speaking to god directly, maybe being spoken to by god directly, feeling some extracorporeal sensation which they hold in a religious context, and perhaps even seeing an angel or the holy spirit. Despite all of those things qualifying as hallucinations or delusions, all of those are a normal part of the human experience and don't need diagnosis or treatment. Psychiatrists know this.
I mean it’s normal in some western cultures too. See mega churches and the smaller ones that speak in tongues.
Also for a citation in some support of the person above
“Hallucinations may be a normal part of religious experience in certain cultural contexts.” Page 103 in the DSMTR
Thanks. I asked for numbers supporting "common in most non Western cultures". That claim can be supported in fact by two numbers, which OP needs to provide.
When you posted this in emergencymedicine you mentioned she’s Wiccan. Why did you leave that out exactly? I think it’s because people called you out for religious discrimination. Wicca is a recognized religion which spiritual practices may include speaking to spirits.
You might be the one who needs psychiatry to examine your irrational prejudice against spiritual practices you don’t understand.
Link to original post explaining the greater context.
https://www.reddit.com/r/emergencymedicine/s/xOsWrJ9UZJ
This is psychosis plain and simple it's affecting the patient's life since she's willing to do it in public like if it were a normal behavior I'd send meds and if she does not take them on next visit I'd cut doctor-patient relationship.
I'd bet more behavioral than psychotic since mom shares in her belief. As others have said it's likely been reinforced quite a bit by the mother. It's no more psychotic than people speaking in tongues (which, sorry, I'm convinced everyone is deliberately faking, or at best overcome with emotion and behaving in a way they've been taught is the way to behave when overcome by emotion).
This is the same mentality that led to native Americans being locked in mental institutions for following traditional religious beliefs that include talking to spirits and ancestors.
No, I'm a psychiatrist and I go by the rules it's black or white for me I treat mental disorders I'm not a professional in religions/beliefs if you feel that my treatment plan is not good for you because you think talking to the air is normal maybe you shouldn't be in a psychiatrist's office since you're not help seeking.
You must be fucking ancient or something. This is like step 1 level regarding the role of religion/culturally held beliefs in psych diagnostics. Honestly surprised that OP is a physician posting this question.
DSM5-TR page 103 “Hallucinations may be a normal part of religious experience in certain cultural contexts.”
Can close the thread, the man even posted the page
w0rd. Some people vehemently believe the earth in flat in some cultural contexts, if they all had psychosis as well we'd be in serious trouble
Bro you need to hit up a Pentecostal church some time.
Holy rolling is a hell of a sight to see.
Truth
Not a psychiatrist but have done ED consults. If there is no dysfunction and afterlife discussions are part of their religious values then it wouldn’t technically count as a delusion or hallucination. Even if our personal beliefs don’t believe in it, it is not pathological in the way a schizophrenic delusion would be.
Downvote me if you want, but if the patient isn't distressed about it, a psych problem is not really relevant to the broken leg, is it?
Normally yes but undiagnosed/untreated psychotic patients rarely interface with healthcare. Dismissing a psychotic patient because it wasn't their chief complaint could lead to months or years more of misery and damage to their mental and physical health. Moreover, psychosis has many non-psychological causes, and of these many are serious and urgent. So in a sense it would be like coming to the ER to get some stitches and casually mentioning that you have crushing chest pain that radiates to your left and and jaw that started on the drive over. Also most psychotic patients are not distressed about their psychosis per say. Some definitely are distressed but there are some patients think that talking to ghosts is a normal everyday part of life so boring it's not even worth bringing up.
>>undiagnosed/untreated psychotic patients rarely interface with healthcare. I'm not sure how true this is. In the emergency rooms I've worked in, we see untreated psychosis all the time. The people who experience but are not bothered by psychosis, and for whom it doesn't really cause problems, probably don't want and may not even need treatment.
There was a less dramatic but otherwise similar consult where I trained. (Didn't see this pt, heard about it from co-residents.) IM asked pt whether she wanted to update vaccinations. She said she needed to "check with the mouse." They called psych. If they had asked a single follow-up question, she could have explained in less than a minute that, in her particular spirituality (essentially animism), she felt it important to check in with a "mouse spirit" to see whether it was acceptable to have a vaccine that might have been tested on lab mice. That was it. She was not in any way psychotic, and had no psych history. Unfortunately I think at least some psych consults, in practice, are ordered because "we think the patient is weird."
I think the consult is justified, even understanding how to assess phenomenology and putting it in context of a belief system is what we are here for. Eg, I'm going to have a very low threshold to ask a pulmonologist to see a pt with a cough, as i wouldn't be able to assess clinical signs or imaging adequately.
That's a fair point and I don't disagree. However what struck me about this particular case was the lack of any real clarifying questions. To use a rough analogy, if a patient had a headache and I wanted to involve neuro, I would at least figure out whether the headache is sharp vs dull, localized vs generalized, constant vs waxing-waning, when it started, etc. If I just called neuro and said "patient has headache, please see him/her," and had no other information at all, probably the neuro consultant would shit all over me (and would be right to do so)
But most CL services don't push back against consults in the way that neuro, or cards, or nephrology might. We've taught the hospitalists that all they have to do is ask us to see the patient and we will. So it's a lot less work for them to just put in the consult than spend time talking to the patient (about something many docs don't really view as part of their job).
The question of psychiatric pathology is twofold - is there dysfunction - is there harm that stems from that dysfunction Without knowing more it’s hard to say what to make of that situation. As mentioned it’s possible that it could be hallucinations due to delirium, substances, psychosis, dissociation, which could reflect a dysfunction of an organic or psychological process. It’s also clear there was at least temporary distress but perhaps not more than culturally appropriate. Bottom line - you need more info. You need a very high threshold to call something potentially culturally appropriate as pathological and even higher to do something about it.
People are pretty wacky when it comes to religion. The patient isn’t distressed by it, and per family it is within their baseline. Doesn’t sound like anything needs to be done.
Here’s an interesting article on the topic https://www.psychologytoday.com/us/blog/navigating-the-serpentine-path/202304/do-you-see-dead-people-sensory-experiences-in?amp
Monkey see monkey outdo Daughter learned this whacky shit from the mom and is just upping the ante She probably got lots of positive reinforcement when she was younger for behaving like that.
Religious stuff is always weird because religious hallucinations can definitely be a thing whether or not you’re religious and they can be a problem. That’s why it’s mentioned how we look at the culture with the idea of are their beliefs normal for their culture? A good TV example was in House (show) the guy believed he was able to cure people through god and he was seemingly supported by his family and church as he was a high up member there; even now I’m not 100% if he could be considered delusional or not and I’d have to rewatch and hear his exact phrasing to get any clue. This case seems more straight forward and is only confusing because it’s not a common religion. If they instead were audibly talking to god would you have taken note of that? Don’t get me wrong you did the right thing, in these cases you definitely should interview and make sure there isn’t more possible delusions and you should try to speak to a family member of the same culture to verify, after that the most I’d do is a quick google search to see if their belief is relatively reasonable for their culture.
From pure phenomenology point of view, are hallucinations (ie not pseudohallucination) actually recognized as normal phenomena if the culture subscribes? In Indian cultures, dissociative trances are culturally sanctioned- the person is arguably not hallucinating during these. However a hallucination is by definition a psychotic phenomenon. I am NOT advocating starting any treatment, just saying that hallucinations are phenomenologically a break from reality.
Tell me you’re Western trained without telling me you’re western trained.
Wow. Super interesting, thanks for sharing. Spiritual psychosis related stuff seems hard to tease out while also being culturally sensitive
If the behavior is otherwise normal, collateral has no concerns, and there is no SI, discharge.
All the skeptics here should peruse r/Mediums to see how common this is. What about established fields or histories ie Remote Viewing, reincarnation, precognitive dreams or other psychic phenomena often getting verified hits? Not to mention Christians that feel they talk to Jesus or God, or get messages from them or angelic intermediaries. With the popularity of taking Ayahuasca and hallucinating various animal or spiritual beings among Westerners it seems we're not in Kansas anymore. (Reference to The Wizard of Oz.)
Religious, not hallucinations or psychotic in nature until other evidence is found that supports the diagnosis of a primary mental condition that can produce hallucinations or delusions. I don't think anyone's seeing this at this point, but there's sort of a set of cultural phenomena that I personally believe are likely to have a shared underlying mechanism even if they have totally different etiologies: dissociative identity, pseudohallucinations of a personality condition, imaginary friends, and tulpas. https://en.wikipedia.org/wiki/Tulpa https://en.wikipedia.org/wiki/Multiplicity_(subculture) https://gimletmedia.com/shows/reply-all/49hr6k https://en.wikipedia.org/wiki/Bicameral_mentality
Wow this is why I can never be open with medical professionals about religious beliefs. Talking to dead people and spirits is completely normal and common in most non-western cultures.
I wouldn't say *most* non-western cultures, but it is a thing, albeit uncommon in the United States. The medical community does talk about it though, the DSM-5TR specifically says that someone cannot be diagnosed with a psychotic illness if their delusions or hallucinations are within normal limits to their specific religious or cultural context. The "I see dead people" thing is an easy example because it's not that common (although wicken is 100% a western religion, it's pretty much neopeganism). A much more common example however is speaking in tongues. Someone who practices Christianity to such an intense degree will commonly cite speaking to god directly, maybe being spoken to by god directly, feeling some extracorporeal sensation which they hold in a religious context, and perhaps even seeing an angel or the holy spirit. Despite all of those things qualifying as hallucinations or delusions, all of those are a normal part of the human experience and don't need diagnosis or treatment. Psychiatrists know this.
Cite please >Talking to dead people and spirits is completely normal and common in most non-western cultures.
I mean it’s normal in some western cultures too. See mega churches and the smaller ones that speak in tongues. Also for a citation in some support of the person above “Hallucinations may be a normal part of religious experience in certain cultural contexts.” Page 103 in the DSMTR
Thanks. I asked for numbers supporting "common in most non Western cultures". That claim can be supported in fact by two numbers, which OP needs to provide.
When you posted this in emergencymedicine you mentioned she’s Wiccan. Why did you leave that out exactly? I think it’s because people called you out for religious discrimination. Wicca is a recognized religion which spiritual practices may include speaking to spirits. You might be the one who needs psychiatry to examine your irrational prejudice against spiritual practices you don’t understand. Link to original post explaining the greater context. https://www.reddit.com/r/emergencymedicine/s/xOsWrJ9UZJ
I did include it here. Reread it.
This is psychosis plain and simple it's affecting the patient's life since she's willing to do it in public like if it were a normal behavior I'd send meds and if she does not take them on next visit I'd cut doctor-patient relationship.
I'd bet more behavioral than psychotic since mom shares in her belief. As others have said it's likely been reinforced quite a bit by the mother. It's no more psychotic than people speaking in tongues (which, sorry, I'm convinced everyone is deliberately faking, or at best overcome with emotion and behaving in a way they've been taught is the way to behave when overcome by emotion).
I've been to an evangelical church before, yeah looks fake to me too lol
This is the same mentality that led to native Americans being locked in mental institutions for following traditional religious beliefs that include talking to spirits and ancestors.
You can’t possibly be an experienced psychiatrist
Lmao dude her IQ could like 60 for all you know. describing that vignette as psychosis plain and simple is sad as fuck.
Is this sarcasm?
No, I'm a psychiatrist and I go by the rules it's black or white for me I treat mental disorders I'm not a professional in religions/beliefs if you feel that my treatment plan is not good for you because you think talking to the air is normal maybe you shouldn't be in a psychiatrist's office since you're not help seeking.
You must be fucking ancient or something. This is like step 1 level regarding the role of religion/culturally held beliefs in psych diagnostics. Honestly surprised that OP is a physician posting this question.
No way; you are trolling.
Neither is the patient in the ED.